Review and Update on Non-Surgical Periodontal Therapy

Antonio Moretti, DDS, MSAssociate Professor

Dept. of Periodontology

Raleigh-Wake County Dental SocietyOctober 19th, 2010

Presentation Outline

Review of Concepts and Definitions

Diagnosis and Treatment Plan

Initial Periodontal Therapy

◦ Oral hygiene instruction

◦ Scaling and root planing

◦ Removal of plaque retentive factors

◦ Lasers in non-surgical periodontal treatment

Evaluation of the Initial Periodontal Therapy

Presentation Outline

Additional Topics:

◦ Full-Mouth Disinfection◦ Topical Antimicrobials◦ Systemic Antibiotics◦ Locally Delivered Antimicrobials◦ Periodontal Host Modulation

Final Remarks

REMEMBER THIS ALWAYS …

There is no substitute for an accurate periodontal diagnosis and adequate conventional (i.e., mechanical) periodontal treatment.

Periodontal Diagnosis

Full mouth series of radiographs including bitewings

Full mouth periodontal chart◦ Bleeding on probing◦ Plaque Index

Description of gingival tissues Description of calculus presence Risk assessment and goals of treatment Thorough discussion with patient

regarding findings and treatment plan

Example of Clinical Case

Periodontal Chart

Periodontal Risk Assessment

Periodontal Diagnosis Example of chart notes for 1st visit:

Purpose: Initial comprehensive examination Chief Complaint: History of Chief Complaint: Medical History: Dental History: Oral Hygiene/Gingival Tissues: Plaque Index, Percentage of BOP Calculus (location, quantity, distribution): Treatment Provided: Full-mouth periodontal charting (probing depth, clinical

attachment level, bleeding on probing, mobility, furcation involvement). Explanation of initial findings. Treatment plan explained.

Evaluation:◦ Radiographic Findings:◦ Periodontal Diagnosis (AAP, 1999 Workshop):◦ Additional Clinical Findings:◦ Occlusal Factors:◦ Restorative Factors:◦ Risk Assessment and Periodontal Prognosis:

Short Term (< 5 years): whole dentition __ versus selected teeth __ Long Term (> 5 years): whole dentition __ versus selected teeth __

Periodontal Diagnosis Suggested Treatment Plan:

- Education on the etiology of periodontal disease- Oral hygiene instructions and motivation- Four quadrants of scaling and root planing (SRP)- Minor/initial restorative care- Reevaluation of initial periodontal therapy 4-8 weeks after last quadrant of SRP- Surgical Phase (including antibiotic therapy):

- Maxillary right - Maxillary left- Mandibular right- Mandibular left

- Reevaluation of surgical therapy 6-8 weeks after the last quadrant of surgery.- Completion of Restorative Phase and Other Treatment Needs- Periodontal maintenance at 3-month intervals or according to patient's plaque control

Evaluation: Next Visit:

Periodontal Diagnosis

Routine Chart Notes:

◦ P - purpose

◦ H – medical history

◦ O – oral hygiene

◦ T – treatment provided

◦ E - evaluation

◦ N – next visit

Periodontal Diagnosis

Reference for Periodontal Diagnosis:◦ Armitage G.C.: Development of a Classification System for Periodontal Disease and Conditions. Ann Periodontol 1999; 4:1-6.

http://www.joponline.org/toc/annals/4/1

Reference for Periodontal Risk Assessment:http://www.previser.com/

Reviewing Concepts:

Probing Depth, Attachment Level and Bleeding on Probing

Periodontal Diseases Are Infections

Gingivitis

Chronic Periodontitis

Aggressive Periodontitis

Experimental Gingivitis in Man

Gingivitis (~15 to 21 days)

Health (~7 to 10 days)

Löe et al., 1965

Host Immune &

Inflammatory

Responses

Microbial

Challenge

Clinical Signs

of Disease

Initiation and

Progression

Genetic Risk Factors

Environmental and Acquired Risk Factors

Pathogenesis of Periodontal Disease

LPS

Ag

Ab

PMNs

Cytokines/PGE

Osteoclast

activation

MMP

Other virulence

factors

CT and Bone

Metabolism

Initial Periodontal Therapy

Patient education and motivation Oral hygiene instruction/daily antimicrobials Scaling and root planing combined or not

combined with antimicrobials Removal of additional retention factors for

plaque, such as overhanging margins of restorations, ill-fitting crowns, etc.

Minor restorative work Extraction of hopeless teeth Reevaluation in 4-8 weeks after last ScRP

Criteria for Periodontal Surgery

Gingivitis OHI + ScRP

Slight Periodontitis OHI + ScRP

Moderate Periodontitis OHI + ScRP

Surgery (?)

Severe Periodontitis OHI + ScRP

Surgery

Nosurgery

Initial Periodontal Therapy:

Mechanical & Chemical Aspects

Patient Education and Motivation

Current Concepts: Mechanical Plaque Control

Mechanical plaque control: the best approach for the prevention and treatment of gingivitis.

Prevention of gingivitis requires only meticulous removal of plaque every 48 hours.

In general, no more than 60% of the overall plaque is removed at each episode of oral hygiene.

Claydon, 2008

Current Concepts: Mechanical Plaque Control

The main benefit of twice-a-day oral hygiene is the adjunctive chemical action of the dentifrice.

Epidemiological studies have shown that gingival health improves with up to twice-daily brushing but not more frequently than that.

Claydon, 2008

Current Concepts: Mechanical Plaque Control

Toothbrush design:◦ Handle size: Long contoured handle performs better than short and flattened.

◦ Head size: Small is best.

◦ Filament: Arrangement and height do not matter. High-filament density is more effective.

◦ Automated brushes …

Claydon, 2008

Partial Classification of Powered Toothbrushes by Mode of Action

Design Mode of Action and Brand Example

Lateral Motion Brush head action that moves laterally from side to side.Philips Sonicare: www.philips.com

Counter Oscillation

Adjacent tufts, containing between 6 and 10 filaments, rotate in one direction and then counter-rotate with adjacent tufts moving in opposite directions.Interplak Brush: www.conair.com

Rotation Oscillation

The whole brush head rotates in one direction followed by the other.Oral B Braun: www.oralb.com ; Colgate Motion: www.colgate.com

Sonic 300,000 strokes per minute: Sensonic: www.waterpik.com20,000 strokes per minute: Colgate 360: www.colgate.com

Ultrasonic The toothbrush filaments vibrate at ultrasonic frequencies (>20 kHz)Ultrasonex Brush: www.saltoninc.com

Ionic An electric current is applied to the filaments during toothbrushingthat alters the charge polarity of the tooth and results in the attraction of dental plaque towards the filaments and away from the tooth. No automated action is provided.Hukuba Ionic: www.ionicbrush.com

Sonicare Interplak Oral B

Sensonic Ultrasonex Colgate Sonic

Powered Toothbrushes

Higher compliance: one study showed 62% of participants continued daily use for 36 months

Sales of powered toothbrushes doubled between 1999 and 2001

Powered toothbrushes may remove 84% of the plaque in 2 minutes and 93% in 6 minutes

Claydon, 2008

PLAQUE reduction for powered vs. manual toothbrushes at (1-3 months) and (>3 months)

Type of Toothbrush

Number of Studies Number of Participants

Effect size

1-3 months > 3 months 1-3 months > 3 months 1-3 months > 3 months

Lateralmotion

6 2 402 220 None None

Counter oscillation

4 2 184 69 None Moderate

Rotationoscillation

15 3 1181 266 Moderate Moderate

Circular 3 1 168 40 None None

Ultrasonic 3 1 171 46 None None

Ionic 3 1 179 64 None Slight

Claydon, 2008

GINGIVITIS reduction for powered vs. manual toothbrushes at (1-3 months) and (>3 months)

Type of Toothbrus

h

Number of Studies Number of Participants

Effect size

1-3 months > 3months 1-3 months > 3 months 1-3 months > 3months

Lateralmotion

8 2 627 220 None None

Counter oscillation

4 2 172 69 None None

Rotationoscillation

16 4 1256 423 Moderate Moderate-High

Circular 3 1 168 40 None None

Ultrasonic 3 1 171 46 None None

Ionic 2 1 116 64 None Slight

Claydon, 2008

Interdental Cleaning

No systematic reviews available

Overwhelming number of options:◦ Floss or tape, super floss and flossers

◦ Woodsticks or brushes (single or multi-tufted)

◦ Mechanical or electrical devices

The general population lacks:◦ Knowledge

◦ Motivation

◦ Skill

Clinical Studies on Oral Hygiene

Stewart and Wolfe 1989

Lack of reinforcement of oral hygiene over time increased poor compliance.

MacGregor et al1998

2-10% of the population floss regularly and effectively.

Bader 1998 A substantial part of the population never floss at all.

Beals et al 2000 Patient’s average brushing time is 37 seconds.

Kalsbeek et al 2000 Only 10% of the population floss daily.

Lang et al 2004 Only 20% of the patients regularly perform acceptable flossing.

Efficacy of Dental Floss

The dental professional should determine, on an individual basis, whether high quality flossing is an achievable goal. Routine instruction to use floss is not supported by scientific evidence.

Berchier et al., 2008

Bacterial Putrefaction

Peptides/Proteins

Amino Acids

Putrefaction Products(volatile sulfur compounds)

Oral Malodor

Proteolysis

Aminolysis

Breath VSC & Some Amines

Name Odor Qualification

Hydrogen sulfide Rotten eggs

Methyl mercaptan Pungent, rotten cabbage

Dimethyl Sulfide Unpleasantly sweet

Allyl methyl sulfide Garlic-like

Carbon disulfide Slightly pungent

Dimethylamine Fishy, ammoniacal

Trimethylamine Fishy, ammoniacal

Tongue Coating

Winkel et al., 2003

Light

Irrigation Devices

Water jet: 1,200 pulsations per minute with pressure of 55-90 psi reduces bleeding and gingivitis.

Pulsation action:◦ Impact zone: where the solution initially contacts in the mouth at the gingival margin

◦ Flushing zone: where the water or other irrigant reaches subgingivally

Gorur et al, 2009 and Ciancio et al, 2009

Showerbreeze Quickbreeze Redibreeze

Waterpik

Conair Interplak

Deep Pocket Syringe

Dental Water Jet Reduction of Inflammation and Biofilm

Study Duration N Agent Used % Bleeding Reduction

% GingivitisReduction

% PlaqueReduction

Al-Mubarak et al 2002

3 months 50 Water 43.4 66.9 64.9

Barnes et al 2005 4 weeks 105

Water 36.2-59.2 10.8-15.1 8.8-17.3

Brownstein et al 1990

8 weeks 44 CHX (0.06%) 52-59 25.4-31.1 14.3-19

Burch et al 1983 2 months 47 Water 57.1-76.6 29.3-37.7 52-55.7

Chaves et al 1994 6 months

105

CHX (0.04%)Water

5450

2626

3516

Ciancio et al 1989 6 weeks 61 ListerineH2O/Alcohol 5%

27.613.6-31.2

54-55.759.9-61.9

23-249.6-13.3

Cutler et al 2000 2 weeks 52 Water 56 50 40

Flemmig et al 1990

6 months

175

CHX (0.06%)Water

35.424

42.523.1

53.20.1

Ciancio, 2009

Dental Water Jet Reduction of Inflammation and Biofilm

Study Duration N Agent Used % Bleeding Reduction

% GingivitisReduction

% PlaqueReduction

Flemmig et al 1995

6 months

60 AcetylsalicylicAcid 3%Water

50 8.929.2

55.60

Felo et al 1997 3 months 24 CHX (0.06%) 62 45 29

Fine et al 1994 6 weeks 50 ListerineWater

14.8-21.77.5-10.6

36.8-37.715.5-18.4

Jolkovsky et al 1990

3 months 58 CHX (0.04%)Water

NRNR

33.118.6

51.625.6

Lobene 1969 5 months

155

Water 52.9 7.9

Newman et al 1994

6 months

155

WaterH2O/Zn Sulfate

22.88.8

17.86.5

6.19.2

Sharma et al 2008

4 weeks 128

Water 84.5 38.9

Walsh et al 1992 8 weeks 8 CHX (0.2%)Quinine Salt

4514

770

Ciancio, 2009

Dental Water Jet Reduction of Inflammation and Biofilm (Water Only)

Product # ofStudies

N Duration(months)

% Bleeding Reduction

% GingivitisReduction

% PlaqueReduction

Waterpik 16 1225 1-6 22.8-84.5 10.8-66.9 0.1-64.9

OxyJet 1 64 2 26 11 4.4

HydroFloss

2 69 3 No dataNon-significant

40% (anteriorteeth)2.2

Ciancio, 2009

Chemical Plaque Control:Dentifrices

Dentifrices

An agent with antiplaque activity must have demonstrated a significant benefit on gingival health in randomized controlled studies of at least 6 months duration to receive approval by the ADA.

Main components:◦ Mild abrasives to remove debris and residual surface stains. Examples:

calcium carbonate, dehydrated silica gels, hydrated aluminum oxides, magnesium carbonate, phosphate salts and silicates.

◦ Fluoride to remineralize tooth. All ADA-Accepted dentifrices contain fluoride. ◦ Humectants to prevent water loss. Examples include glycerol, propylene,

glycol and sorbitol. ◦ Flavoring agents, such as saccharin and other sweeteners to provide taste.

(No ADA-Accepted dentifrices contain ingredients that would promote caries.)

◦ Thickening agents or binders to stabilize the formula. They include mineral colloids, natural gums, seaweed colloids or synthetic cellulose.

◦ Detergents to create foaming action. They include sodium lauryl sulfate, sodium N-Lauryl sarcosinate.

ADA Approved Dentifrices (>50)

Company Name: Number of Products:

1 Church & Dwight Co., Inc. 2

2 Colgate-Palmolive Co. 18

3 Del Laboratories, Inc. 1

4 Dental Technologies, Inc. 2

5 GlaxoSmithKline Consumer Healthcare 4

6 JM Murray Center, Inc. 3

7 Keefe Group 1

8 Optimal Healthcare Products, LLC 1

9 Plak Smacker 2

10 Procter & Gamble Co. 11

11 Sheffield Pharmaceuticals 2

12 Tom's of Maine 7

www.ada.org

Studies of 6 months’ duration involving stannous fluoride dentifrices

Study Active Control Plaque %reduction vs. control

Gingivitis %reduction vs.

control

Beiswanger et al 1995

SnF NaF 3 19*

Beiswanger et al1997

SnF NaF -2 18*

Mankodi et al 1997 SnF NaF 20* 21*

Mankodi et al 2002 SnF MFP 7* 22*

McClanahan et al 1997

SnF NaF 3 21*

Perlich et al 1995 SnF NaF 3 21*

Williams et al 1997 SnF NaF 23* 22*

NaF, sodium fluoride; MFP, sodium monofluorophosphate; SnF, stannous fluoride.* Statistically significant Davies, 2008

Studies of 6 months’ duration involving triclosan/copolymer dentifrices

Study Active Control Plaque %reduction vs. control

Gingivitis %reduction vs.

control

Allen et al 2002 Tric/copoly NaF 30* 23*

Bolden et al 1992 Tric/copoly NaF 17* 29*

Cubells et al 1991 Tric/copoly NaF 25* 20*

Deasy et al 1991 Tric/copoly MFP 32* 26*

Denepitiya et al 1992

Tric/copoly NaF 18* 32*

Garcia-Godoy et al 1990

Tric/copoly NaF 59* 30*

Grossman et al 2002

Tric/copoly NaF 14* 4

NaF, sodium fluoride.* Statistically significant Davies, 2008

Studies of 6 months’ duration involvingtriclosan/copolymer dentifrices

Study Active Control Plaque %reduction vs. control

Gingivitis %reduction vs.

control

Kanchanakamol et al 1995

Tric/copoly NaF 12* 1

Lindhe et al 1993 Tric/copoly NaF 31* 27*

Mankodi et al 1992 Tric/copoly NaF 12* 20*

McClanahan et al 1997 Tric/copoly NaF 0 2*

Palomo et al 1994 Tric/copoly NaF 11* 21*

Svatun et al 1993 Tric/copoly NaF 19* 25*

Triratana et al 1993 Tric/copoly NaF 35* 26*

Winston et al 2002 Tric/copoly Naf 9 0

NaF, sodium fluoride.* Statistically significant Davies, 2008

Chemical Plaque Control:Mouthrinses

Antimicrobial Mouthrinses

For most of our patients, biofilm cannot be suppressed by mechanical methods only

Evidence supports the adjunctive use of mouthrinses in a daily basis

Main brands available in the US market are all safe products

Summary of Placebo-Controlled Trials of Chlorhexidine (CHX) & Listerine in Gingivitis Patients

CitationTrial

Length(months)

No. of Patients

AgentPlaque

Reduction (%)

Gingivitis Reduction

(%)

Grossman et al. 1989 6 481CHX

0.12%49

31

Grossman et al. 1986 6 380CHX

0.12%61 39

Löe et al. 1976 24 120 CHX 0.2% 45 27

Lang et al. 1982 6 158CHX 0.1% CHX 0.2%

1619

6780

Gordon et al. 1985 9 85 Listerine 20 24

Lamster et al. 1983 6 145 Listerine 22 28

Overholser et al. 1990 6 124 Listerine 36 36

Charles et al. 2001 6 316 Listerine 56 23

DePaola et al. 1989 6 107 Listerine 34 34

Take Home Messages:Dentifrices & Mouthrinses

Meta-Analysis

Systematic review of literature to evaluate the efficacy of antigingivitis and antiplaque products in six-month trials.

Seventeen studies support the antiplaque, antigingivitis effects of dentifrices containing 0.30% triclosan and 2.0% gantrez copolymer.

There is no evidence of efficacy for triclosan with either soluble pyrophosphate or zinc citrate.

Meta-Analysis

Stannous fluoride is both clinically and statistically significant as an antigingivitisagent.

Twenty-one studies support essential oils as efficacious mouthrinses.

Seven studies support a strong antiplaque, antigingivitis effect for 0.12% CHX.

Gunsolley, 2006

JADA December Issue

Scaling and Root Planing: Rationale

• Smooth surfaces are easier to clean and maintain

• Less potential to accumulate plaque and calculus

• To eliminate biologically-incompatible cementum/dentin (cementum-bound endotoxin)

• To make root surfaces biologically compatible for healing and long-term care

Correction of Defective Restorations

Instruments and Instrumentation

What is new?

Should we consider changes?◦ Hand instruments

◦ Ultrasonic and Sonic instruments

◦ Rotating instruments

◦ Reciprocating instruments

◦ Laser instruments

Curettes

Files

Have a series of blades

Can fracture or crush calculus

Can gouge root surfaces if used incorrectly

Examples: Hirschfield and Orban

Furcation Curettes and Files

Dental Implant Curettes & Others

Sonic and Ultrasonic Inserts

Instrument Sharpening

Sharpening

Which one would you use?

Removal of Calculus

Sites with PD >5 mm have consistently shown remaining calculus after “closed” ScRP.◦ Waerhaug, 1978

◦ Rabbani et al., 1981

◦ Magnusson et al., 1984

◦ Sherman et al., 1990

Surgically treated sites have shown improved efficacy of scaling and root planing.◦ Eaton et al., 1985

◦ Caffesse et al., 1986

Other Factors

Root anatomy◦ Single-rooted vs. multirooted◦ Concavities◦ Tooth furrows

Skill of the operator (Brayer et al., 1989)

◦ Experience becomes more relevant in deep probing depth (>6mm) sites.

Time allowed (Badersten et al., 1981)◦ Hand instruments: 6-8 min. per tooth◦ Ultrasonic instruments: 4-6 min. per tooth

Calculus Detection

• Instruments:•Explorer EXD 11/12•Caries explorer 17

• Gentle air stream• Gauze pressure/drying• Soft tissue coloration• Root should feel:

•Smooth•Hard

• No calculus left behind

Ultrasonic and Sonic Scalers

Outcome: uneven root surface

Supplement with hand instrumentation for smoother surface (Björn & Lindhe, 1962)

Clinical studies on ScRP with ultrasonic or hand instruments have shown that 4-7 mm pockets responded equally well to either technique

◦ Torafson et al., 1979

◦ Badersten et al., 1981

Is a smooth surface really needed?

Junctional epithelium readapts to root surface after ScRP in uneven root surfaces.

◦ Waerhaug, 1956

Ultrasonic instrumentation is considered the best instrument for ScRP in furcation areas.

◦ Leon & Vogel, 1987

Ultrasonic vs. Sonic

Sonic is air driven and vibrations are generated mechanically.

Vibrations of 2,000-6,500 cycles per second (Hertz)◦ Studies: in vitro (Lie & Leknes, 1985) and clinical (Loos et al., 1987 and Baehni et al., 1992) have shown that sonic scaler was as effective for calculus removal as the ultrasonic instrument.

◦ Sonic scaler caused less root surface roughness than ultrasonic.

Ultrasonic

Ultrasonic vibrations are produced by a metal core which can change dimension in an electromagnetic field with operating frequency between 25,000 and 45,000 cycles per second (Hertz).

Two types of ultrasonics:

◦ Magnetostrictive – elliptic vibration

◦ Piezoelectric – linear vibration

Sonic and piezoelectric generate less heat than magnetostrictive. Water cools frictional heat only and helps flushing away debris.

Ultrasonic

• Reduction of time and fatigue• All aspects of the tip work• Uses water for cooling and lavage• Improved access to areas such as furcations

• TF 10 (Black) for heavy calculus removal• Slim-line (Green) for finishing and access

Piezo Power Scaling

Reciprocating Instruments

Profin®

Eva®

PER-IO-TOR®

◦ Similar planing properties to manual hand instruments with minimal removal of tooth structures (Mengel et al., 1994)

1.2 mm reciprocating motion

Results After the Use of Reciprocating Instruments

Laser Instruments

Er:YAG (erbium-doped: yttrium, aluminiumand garnet laser) has been used for ScRPwith early positive results.

There is lack of evidence that this technology offers true advantage when compared to traditional methods.

There is no evidence to support the superiority of the Nd:YAG laser over traditional modalities of periodontal therapy.

Cobb, 2006

Slot et al, 2009

Laser TypeCommon

AbbreviationDelivery Tip Reported Periodontal Applications

Carbon dioxide CO2

Hollow waveguide; beam focused when 1 to 2 mm from target surface

Soft tissue incision and ablation; subgingival curettage

Neodymium:yttrium-aluminum-garnet

Nd:YAGFlexible fiber optic system of varying

diameters; surface contact required for most procedures

Soft tissue incision and ablation; subgingival curettage and bacterial

elimination

Holmium:yttrium-aluminum-garnet

Ho:YAGFlexible fiber optic system; surface

contact required for most procedures

Soft tissue incision and ablation; subgingival curettage and bacterial

elimination

Erbium:yttrium-aluminum-garnet

Er:YAGFlexible fiber optic system or hollow

waveguide; surface contact required for most procedures

Soft tissue incision and ablation; subgingival curettage; scaling of root surfaces; osteoplasty and

ostectomy

Erbium, chromium:yttrium-selenium-gallium-

garnet

Er,Cr:YSGGSapphire crystal inserts of varying

diameters; surface contact required for most procedures

Soft tissue incision and ablation; subgingival curettage; osteoplasty

and ostectomy

Neodymium:yttrium-aluminum-perovskite

Nd:YAPFlexible fiber optic system; surface

contact required for most procedures

Soft tissue incision and ablation; subgingival curettage and bacterial

elimination

Indium-gallium-arsenide-phosphide; gallium-aluminum-arsenide; gallium-

arsenide

InGaAsP (diode) GaAlAs (diode) GaAs

(diode)

Flexible fiber optic system; surface contact required for most procedures

Soft tissue incision and ablation; subgingival curettage and bacterial

elimination

Argon Ar Flexible fiber optic system Soft tissue incision and ablation

Air Polishing

Air-powered slurry of warm water and sodium bicarbonate.

Ideal for extrinsic stain removal and soft deposits.

Tooth structure can be lost and gingival tissue injury can occur if improperly used.

Other powder:

aluminum trihydroxide

Air Polishing

Contraindications: respiratory illnesses, hypertension, sodium restricted diets, or medications affecting electrolyte balance.

Use pre-procedural rinse with 0.12% chlorhexidine gluconate to minimize the microbial content aerosol.

High-speed evacuation should always be used.

Perioscopy

Perioscopy

Clinical studies:◦ The use of periodontal endoscope resulted in

statistically significant improvement in calculus removal during ScRP, which was most evident in deeper PD sites

◦ The clinical significance of this level of improvement is unknown

Geisinger et al., 2007

◦ Periodontal endoscope use in ScRP provided no significant improvement in calculus removal in multirooted molar teeth

Michaud et al., 2007

Healing after Initial Therapy

Outcome of Therapy

Long junctional epithelium

1. Gingival Recession2. Reduction of PD and slight gain in CAL3. Reduced BOP4. Radiographic bone fill

ClinicalOutcome of Therapy

6mm8mm

5mm

5mm 6mm 3mm

Resolution of inflammation

Gingival Recession

Radiographic Outcome of Treatment

Pre tx.

ScRP only

4 mo.

Gingival Flap & ScRP

Pre tx.

6 mo.

Results After ScRP(Non-Molar Sites)

Initial Probing Depth

Probing Depth Reduction

Attachment Change

< 3 mm 0.5 mm - 0.5 mm

3-6 mm 1.0 – 1.5 mm - 0.5 /+ 0.5 mm

7->10 mm 2.5 – 5.0 mm + 0.5/+2.0 mm

Full-Mouth Disinfection (FMD)

Conventional ScRP (q 2 weeks) Full-mouth ScRP (within 24 hours) Full-mouth disinfection (Quirynen et al., 1995)

◦ ScRP in 24 hours combined with antimicrobials (CHX rinses, subgingival irrigation, tongue debridement)

◦ Prevent re-colonization of bacteria coming from other niches in the mouth (e.g., pockets, tongue, etc.)

Seven randomized clinical trials (at least 3 months duration) showed a modest advantage for FMD (i.e., PD reduction and CAL gain)

Cochrane Database Syst Rev 2008

Full-Mouth Disinfection (FMD)

FMD with CHX use only may lead to pyrexia Use of systemic antibiotic has been

suggested FMD with azithromycin 3 days before

procedure has shown benefitsGomi et al., 2007

Clinicians should select the treatment modality based on practical considerations related to patient preference and clinical workload

Kinane & Papageorgakopoulos, 2008

Summary & Conclusions on ScRP

Critical and relevant phase of periodontal therapy.

Important to understand soft tissue response Develop a professional relationship with

patient. Success of therapy may lead to no surgery. ScRP is a time-consuming and technique-

sensitive procedure. Before delegating this form of treatment, the

dentist needs to understand all technical and scientific aspects related to this topic.

Antibiotics/Antimicrobials & Drug Delivery

Topical

Systemic (peroral)

Controlled-release: polymers to control drug concentrations

Systemic Antibiotics

Systemic Antibiotics in Periodontics

For common forms of gingivitis and periodontitis, ScRP should always be carried out before antibiotics are administered

Development of resistant bacterial strains is a major concern in medicine

Systemic Antibiotics in Periodontics:Main Indications

Refractory Cases Aggressive Periodontitis Medical conditions Acute periodontal infections

◦ Periodontal abscess◦ NPD: NUG/NUP

Periodontal Regeneration Surgeries

Implant Dentistry Post-surgical infections

Selection of Antibiotics

• Travels easily to infection site• Concentration in GCF, gingiva and bone• Minimal side effects• Research showing efficacy

Single-Drug Regimens

Penicillin◦ Beta-lactam, first antibiotic used in humans◦ Broad spectrum◦ More than 90% of dose is absorbed◦ Bactericidal (inhibits synthesis of cell wall)◦ Useful in initial therapy, abscess, NUG and after periodontal surgery

◦ Low toxicity, allergic reactions◦ Safe drug in general

Single-Drug Regimens

Tetracycline◦ Most commonly prescribed adjunctive agent in periodontal treatment

◦ Broad spectrum/bacteriostatic

◦ GCF concentration 5-7x more than serum

◦ Gastrointestinal disturbance

◦ Photosensitivity, discoloration of mucosa

◦ Discoloration of children’s teeth

◦ No mixture with calcium or metal ions

◦ Candida super infection

Single-Drug Regimens

Minocycline◦ Semisynthetic tetracycline

Doxycycline◦ High compliance (single daily dose)

◦ Useful after scaling and root planing in severe periodontal cases such as aggressive and refractory periodontitis

Single-Drug Regimens

Metronidazole◦ Nitroimidazole, effective against anaerobic bacteria and parasites

◦ No effect on facultative and aerobic organisms

◦ Side effects:

Metallic taste, headache

Vertigo, peripheral neuritis

No alcohol: intestinal disturbance

◦ Used in NUG/NUP

◦ Used in combination therapy with other antibiotics

Single-Drug Regimens

Clindamycin◦ Lincosamide, usually bacteriostatic

◦ Bactericidal in high doses

◦ Similar to erythromycin in terms of spectrum

◦ Main feature: “bone penetration”

◦ Recommended for patients allergic to Penicillin

◦ Side effects:

Diarrhea and gastric upset

Pseudomembranous colitis (rare)

Single-Drug Regimens

Ciprofloxacin◦ Fluoroquinolone

◦ Seems to be beneficial on refractory cases

◦ It may be combined with metronidazole

◦ Adverse effects:

GI upset

Oral candidiasis

Photosensitivity

Single-Drug Regimens

Azithromycin◦ Macrolides Family◦ Bacteriostatic◦ Used for upper and lower respiratory tract infections, including oral infections such as periodontitis, periodontal abscesses and other acute oral infections

◦ It has better absorption than erythromycin due to its high resistance to gastric acids

◦ It achieves high oral soft- and hard-tissue concentration

Combination Therapy

Advantages◦ Broadens antimicrobial range of the therapeutic regimen of a single antibiotic.

◦ Prevents emergence of resistant bacteria through overlapping antimicrobial mechanisms.

◦ Lowers the dose of individual antibiotics by exploiting possible synergy between two drugs.

Combination Therapy

Disadvantages◦ May increase adverse reactions

◦ Potential for antagonist drug interactions with improperly selected antibiotics

Combination Therapy

Do not combine bactericidal with bacteriostatic

Amoxicillin and clavulanic acid – it protects amoxicillin from enzymatic degradation by penicillinase

Augmentin® + Doxycycline (sequential) Amoxicillin or Augmentin® + Metronidazole Ciprofloxacin + Metronidazole

Antibiotics and Dosage Often Used in the Treatment of Periodontal Diseases

Antibiotic Dosage

Amoxicillin with Clavulanic Acid

500 mg 3 x/day for 8 days

Ciprofloxacin 500 mg 2x/day for 8 days

Clindamycin 150 mg 3 x/day for 8 days

Doxycycline 200 mg the first day, then 100 mg/day for 15 days

Metronidazole 500 mg 3 x/day for 8 days

Metronidazole and Amoxicillin

250 mg 3 x/day (each drug) for 8 days

Metronidazole and Ciprofloxacin

500 mg 3 x/day (each drug) for 8 days

Tetracycline 500 mg 3 x/day for 21 days

Cost of Systemic Antibiotics*

Amoxicillin 500 mg 30 caps $ 12.99 Augmentin 500-125 mg 30 tabs $ 166.71 Z-Pak 250 mg Disp Pack $ 62.24 Ciprofloxacin 500 mg 30 tabs $ 117.10 Clindamycin 150 mg 30 caps $ 24.99 Doxycycline 100 mg 30 caps $ 12.99 Doxycycline 100 mg 20 tabs $ 31.99 Tetracycline 500 mg 30 caps $ 15.99 Metronidazole 500 mg 30 tabs $ 12.99

*source: www.drugstore.com

Systemic Anti-Infective Periodontal Therapy: A Systematic Review

Meta-analysis of 22 studies showed consistent benefit in mean CAL change for different populations, for different therapies, and for different antibiotics.

Systemic antibiotics were uniformly beneficial in providing improvement in CAL, when used as adjuncts to ScRP and were consistently beneficial, although of borderline significance, when used as adjuncts to ScRP plus surgery or as a standalone therapy.

Systemic Anti-Infective Periodontal Therapy:A Systematic Review

Found statistically significant improvements for CAL for tetracycline, metronidazole, and an effect of borderline statistical significance for the combination of amoxicillin + metronidazole.

Aggressive periodontitis patients benefited more from antibiotics than chronic periodontitis patients.

Systemic Anti-Infective Periodontal Therapy:A Systematic Review

Due to lack of sufficient sample size for many of the antibiotics tested, it is difficult to provide guidance as to the more effective ones.

Haffajee et al., 2003

Conclusions on Systemic Antibiotics

In periodontics, systemic antibiotics should be an exception rather than the rule.

If indicated, they should be used as adjuncts to mechanical therapy.

They should not be used in cases of poor plaque control.

Evidence has shown that they offer little, if any, adjunctive effect on smokers.

Conclusions on Systemic Antibiotics

They should be considered especially in refractory and aggressive cases of periodontitis.

They should be used in acute conditions and some medical situations.

There is a current trend favoring combined antibiotic therapy (e.g., amoxicillin and metronidazole).

There is still lack of proper guidelines and decision remains empirical.

Topical Antimicrobial Agents for

Treatment of Periodontal Disease

Rationale for UsingTopical Antimicrobial Agents

Pathogens may be unreachable◦ Deep vertical defects

◦ Furcation

◦ Dentin tubules

◦ Biofilm

Systemic antibiotics◦ Adverse reactions

◦ Patient compliance

Principles of Topical Antimicrobial Agents

Local delivery◦ Pocket irrigation

◦ Drug ointment/gel

◦ Prolonged release

Local Delivery Device

Ideally, it should:◦ Establish a drug reservoir

◦ Have effective concentration

◦ Be active for prolonged period of time

Products Available in the USA

Advantages of Controlled-Release Delivery

Prolonged drug levels within therapeutic range

Minimization of harmful or systemic side effects

Protection of drugs with short in vivo half lives

Improvement of patient compliance

Disadvantages of Controlled-Release Delivery

Low volume of the periodontal pocket (0.5 L): Restricts size of the delivery system and total volume of drug-polymer applied.

High turnover rate of crevicular fluid (40 times/hr): Participates not only in drug diffusion but also clearance.

Lingering Questions

Are the improvements with adjunctive locally administered antimicrobials consistent?

Are the clinical improvements with locally administered antimicrobials clinically relevant or meaningful?

Source: Venezia E, Shapira L Oral Diseases 2003

Source: Venezia E, Shapira L Oral Diseases 2003

Source: Venezia E, Shapira L Oral Diseases 2003

Source: Killoy WJ J Clin Periodontol 2002

Source: Killoy WJ J Clin Periodontol 2002

Main Results of Systematic Review(Hanes & Purvis, 2003)

32 studies with 3,700 subjects All studies reported substantial reductions in

gingival inflammation and bleeding Meta-analysis on 19 studies comparing ScRP

alone or combined with antimicrobials showed favoring results for the combined therapy in both PD reduction and CAL gain

American Academy of Periodontology Statement on Local Delivery of Sustained or Controlled

Release Antimicrobials as Adjunctive Therapy in the Treatment of Periodontitis

“The clinician's decision to use locally delivered antimicrobials should be based upon a consideration of

clinical findings, the patient's dental and medical history, scientific evidence, patient preferences, and advantages

and disadvantages of alternative therapies.”

Greenstein, J Periodontol 2006 Review Article

Summary:Antimicrobials in General

Data reaffirm the overall effectiveness of ScRP as the standard of care.

Evidence consistently demonstrates enhanced clinical improvements with adjunctive antimicrobials in patients with chronic periodontitis.◦ Systemic◦ Topical◦ Controlled-release

Clinicians must assess overall patient risks (e.g., disease severity, distribution, smoking) and treatment goals in selecting cases for adjunctive antimicrobial treatment.

Periodontal Host Modulation

In the Periodontium

Pro-inflammatory Mediators (IL-1 , IL-6, TNF ,

PGE2, MMPs) are released

Host Modulators

NSAIDs

Bisphosphonates ?

Statins ?

Low-Dose Doxycycline

Pathogenesis of Periodontal Disease

HealthPink, Healthy Tissue, No Clinical Signs of Disease

Good Oral HygieneLow Susceptibility

No Systemic Risk Factors

Natural Enzyme Inhibitors Tissue Destructive Enzymes

TGFβ, IL-4, IL-10, IL-12, TIMPs IL-1, IL-6, TNFα, PGE, MMP

Pathogenesis of Periodontal Disease

Disease Poor Oral HygieneHigh Susceptibility

Systemic Risk Factors• Smoking

• Genetics• Diabetes

Natural Enzyme Inhibitors

Overproduction

Tissue Destructive Enzymes

Compliance, Cost and Significance

4 times daily 27%

3 times daily 44%

2 times daily 67%

Once daily 89%

• Doxycycline Hyclate (20 mg tabs) _________ 60 tabs = $ 63.98•Doxycycline Hyclate (100 mg tabs) _________ 15 tabs = $ 10.49

Source: www.drugstore.com

Statistical vs. Clinical Significance

Periodontal Host Modulation

There may be a role for the use of host-modulating agents in the treatment of periodontitis in conjunction with conventional therapy.

There may be a publication bias and a tendency for significant or beneficial findings to be published over non-significant results for novel therapies.

Periodontal Host Modulation

Based on data available (meta-analysis) regarding Periostat® with definitive ScRP, it was demonstrated that it provided a statistically significant improvement with respect to PD reductions and gains in CAL when compared to ScRP alone.

The use of Periostat® appears safe and may be an adjunctive aid in the management of chronic periodontitis.

Host Immune &Inflammatory

Responses

Microbial Challenge

CT and BoneMetabolism

Clinical Signs of Disease

Initiation and Progression

Genetic Risk Factors

Environmental and Acquired Risk Factors

Arresting Periodontal Disease Progression

LPS

Ag

Ab

PMNs

Cytokines/PGE

Osteoclastactivation

MMP

Mechanical Therapy

&Antimicrobials:

DentifricesRinses

Antibiotics

Periostat•NSAIDs/Statins?

PeriostatNSAIDs/Statins?

PeriostatBisphosphonates ?

Final Remarks

Clinicians need to decide which patients are at greatest risk for future disease progression. We still lack proper diagnostic tools for this matter.

Currently, there are a number of adjunctive therapy options that clinicians should consider besides mechanical treatment.

THANK YOU !

antonio_moretti@dentistry.unc.edu